Tuesday, July 28, 2009

Healthcare, Oh Boy

So I was asked recently to publish my views on the ongoing healthcare debate facing this country. I’m not sure why my views are so sought out given that I have some obvious vested interests in the issue, but regardless it is a topic of interest to me and I haven’t blogged in awhile so this is a good topic to rebreak the ice on.

To be clear, the issue at hand is the concept of a broad-covering government sponsored ‘insurance’ plan essentially modeled after similar programs like Medicaid for the poor and Medicare for the elderly to include anyone else who doesn’t fit into either of those titles. And apparently there are a whole bunch of Americans who are set in just that fix – 47 million is the number which gets thrown around, but just who are these 47 million Americans?

Did you know that nearly 18 million of them are people from households that make more than $50,000 a year, i.e. people who could afford insurance but opt otherwise? And 8 million or so are between the ages of 18 and 24?Did you know that around 10 million of these uninsured are not citizens of the United States, i.e. those who would not be covered by any of the public options being bandied around Congress anyway (and even should they be covered)?Did you know that about 25% of these uninsured are estimated to already be eligible for existing public programs?

Now these figures likely overlap a bit, but you can pretty easily see that 47 million problems have been cut in at least half, if not more. Do ~20+ million truly uninsurable American citizens require an entire reformation of the system or are there some obvious and simple tweaks we could make that would absorb them into what already exists? Could we do that without costing (likely far more than) a trillion dollars over ten years? Hmm...

It has also been suggested by ‘objective’ assessments of medical care provided by different countries that the United States offers healthcare at about as good quality as Iran, or something to that effect. By counting things like average life expectancy and infant mortality and comparing them to some European nations, it appears that the US comes far inferior. But what these same comparisons fail to realize is that it’s isn’t just healthcare that determines those figures. Americans tend to also be generally more unhealthy in their simple daily diets and activities than those other countries – this alone could leave the statistics showing a reduced life expectancy in America. And unlike in Europe, Americans are far less likely to abort imperfect fetuses and far more willing to try and save premature babies – thereby leading to higher reports of infant mortality.

Additionally, US News and World Reports writes“[I]t's shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don't reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates.”

Now, putting that all aside for now, I’d like to discuss a couple of philosophical problems I have with the idea of these semi-socializing welfare programs in general. The key thing to always keep in mind with welfare programs is that they sound nice and kind, but there ain’t no such thing as a free lunch. See, it’s a great political ploy that works again and again and again whenever it’s tried since not only do politicians get to play the moral high ground by offering the people free healthcare, for example, (as they oppose the opposition which clearly prefers that people die without treatment) – they also get to offer them free stuff! And what electorate can resist the idea of free stuff with the moral superiority package? But it ain’t free – somebody has to foot the bill.

Historically, those who were mandated to pay for the peoples’ insurance were the general taxpayers as they funded Medicaid, Medicare, SCHIP and so on – all unrestrained entitlements that are bankrupting this country. But also corporations and small businesses had to supply their workers with expensive health benefits which was a cost passed simply onto the consumers (ie the American people) and made American products completely uncompetitive on the international markets (which is also part of the reason why the United States is no longer an industrialized nation). And who has recently been suggested to pay for this newest gift to the American people? The middle class, of course. But how smart do you think it is to continue taxing the most productive segments of society – in a recession no less! - to sink money into the least productive? At a certain point, those smart people are going to realize that their hard work and ability is no longer working for them, but against them as they sooner and sooner hit marginal returns on their EARNED rewards. Better for them to work 30 hours a week and keep $150,000 than to work 60 hours a week and take home $200,000, eh? From where then are any of these programs going to be funded? Thus you should be not shocked at all to find that European per capita GDPs tend to be 25% less than America’s.

And despite what people clamor on and on about, healthcare is NOT a right. You cannot have a right to a service that someone else provides. Rights are natural things that surround the idea of personal freedom which others ought not interfere with. You have the right to life, liberty and the pursuit if happiness, but you don’t have the right to impose your will on a medical professional to treat you since that would enslave him and take away his rights. Free people trade value for value and you have the right to pursue professional care of your health through peaceful interactions. Doctors are not serfs and will not put up for long being government property.

Now, with even all of that said, the key thing to recognize is that financially the US healthcare system sucks. The U.S. healthcare system costs double what other countries cost with largely comparable end results. Even though nations with socialized medicine have a degree of rationing – so do we, TODAY. Sure, it’s not the government largely doing the rationing (though it obviously is in part as any Medicare recipient is well aware) but is it better when private insurance companies do not cover everything or have restrictively high premiums? In America we don’t ration by first come first serve, we ration by ability to pay. Better? And even though we don’t have a well organized socialized system, we still mandate that anyone coming in to an ER will be seen and treated – which is essentially the way the government eventually picks up the tab for the uninsured. The uninsured have no provisions for regular visits and simple meds to keep them in health so they show up to the Emergency Room when disaster eventually strikes, costing the system way more than regular upkeep would. So we effectively already have socialized medicine in America, we’re just paying for it ass-backwards.

The solution? I favor the gradual removal of all of these government-sponsored entitlement programs and a return to individual payment for medical care. Way better than any fraud-infested bloated bureaucracy or even any profit-driven corporation, the best person to take care of your own expenses is you. If you’re paying, little doubt you’d pay attention to the reasons for every proposed test, little doubt you’d seek the generic drug when you’re told it works as well as the more expensive new one, little doubt you’d not want to overload the system with minor complaints, little doubt you’d take a measure of responsibility for your own care and know your own history so that your doctor at the new hospital doesn’t need to redo a whole slew of the same tests you got at the hospital in your old town. This reality plus a healthy charity mentality in medicine is the way to go. Healthcare should be recognized as a charity of high regard – millionaires should endow hospitals and individuals can help others in their community. Doctors too should be willing to take a certain number of pro bono cases, since after all, they can afford it now that they are actually receiving the money they billed from their regular patients.

But since this is never going to happen, is a broad covering government insurance option the worst idea? Perhaps not. If creating it removes our other non-afforded entitlement programs then it may be well worth it. But will it end up being the same kind of bloated bureaucracy, with waste and fraud being hallmarks of government involvement - most probably. My prediction: it will happen eventually - it will cost a ton of money, be moderately effective and significantly rationed which will lead to the existence of a two-tiered medical coverage system. People who have private coverage will want to stay private while everyone else will be grouped in the new program. It won’t change medical care all that much but will possibly lead to simpler medical billing for many Americans. Economically we'll get by but with people far less willing to share their earnings charitably (like it is in Europe, charity is a rare gift) and our grandchildren will be the ones still paying the interest on our out of control spending today.

25 comments:

Shai in Israel
said...

I'd be interested in your take on the Israeli medical system. I have found it to be much better than in the US, and much cheaper. I don't know all the ways that's achieved, but surely some of them are controls on medical school expenses (the government subsidizes universities) and doctor's salaries, competing HMO's and government controlled hospital expenses, contracts for drugs negotiated annually with pharmaceutical companies, centralizing and maximizing the use of expensive medical equipment, etc. I've been here more than a dozen years and I've never heard of anybody waiting an unreasonable amount of time for any care they need, and most care is provided almost immediately. co-payments of about $1.00 are frequently waived. Specialist fees of about $5.00 are sometimes charged, but most care is provided by general practitioners. My mother who is in her mid-70's says her care is MUCH better than she got in the US, and her pharmaceuticals are given to her for free. She just got $400 worth of medicines last week for no charge - medicines that would probably cost more in the US. And she pays about $25/month for her medical care. And regarding the kinds of expenses covered, the government HAPPILY pays for women to have fertility treatments, for example. In some things, they are much more generous than America's medical system. I sense that the problem is not how much medical care costs in the US, but who it will be that decides its worth. As you said, you can't force a doctor to provide someone with care. He should decide what's "worth it" to him. But really, isn't that what HMO's do - decide what you'll get paid? I do agree that it's ridiculous to provide medical care to people who aren't citizens. This is a very bad idea and I hope it's dropped. But people who are young and healthy should be forced to pay their part of the medical system's expenses just as they do for social security.

Nice piece. Now since I live under the socialized medical system that Hussein Obama wants to adopt for you guys, let me issue you some warnings:1) Public health care is very expensive. The original assumption in Canada was that health insurance would be like a safety blanket. If the doctor and the hospital are free, you would get a warm fuzzy feeling knowing that it was available if you needed it.In fact, the opposite happened. When something's free, people hoard it. It could be health care. It could be bags of manure. They'll go out and grab as much of it as they can "just in case". Thus the phenomenon where something like 90% of visits to rural ER's up here are for family medicine level concerns but the family doc couldn't see them until tomorrow and they wanted their amoxycillin for that runny nose they've had for 3 hours today! Free = abuse. Done. And that's important because doctors generally charge per visit, unless they're capitated. The more useless visits, the more the cost of the system goes up.2) What's more, if everything is free, including the "Cadillac" tests, then everyone will want them. The guy with obvious tension headaches will want an MRI because his buddy got want and will nag and nag until he gets it. The obese lady with chronic knee pain that is so obviously osteoarthritis will want to see a third Orthopod because the first two didn't think she'd make a good surgical candidate. And on it goes.3) Once something is free and the costs spiral out of control, you're stuck. It might seem sensible to say "Let's stick a $5 user fee on all non-critical ER visits" for example. The howling that'll evoke is incredible. People who have no trouble finding the money for smokes, alcohol and marijuana will claim not to have the money for their kid's ER visit. "I'm on welfare dude, I don't have any cash!" Eventually some single mom's kid will die at home of meningitis because she spent her last 5 bucks at the donut shop and the wailing will begin about how "the system" killed her kid, not her irresponsibility. And that's because...4) Once its socialized, health care doesn't stay a privilege. It isn't even a right anymore. It becomes a religion complete with its own orthodoxy. And just as you can't argue with religious fanatics, you cannot argue with proponents of open-ended take-all-you want health care. If you try to do that up here, you get tarred with the worse insult we Canadians can come up with: "You're just like those Americans!"5) Reality - the only reason Canada can afford its health care system is because we have a tiny army. I mean tiny, like they're all in Afghanistan right now. If someone were to invade us, we would have only the police and some irate trailer trash security guards to defend us. You want national health care? You can't have that and an army. Choose.

"The solution? I favor the gradual removal of all of these government-sponsored entitlement programs and a return to individual payment for medical care"

I.e., let the elderly and disabled fend for themselves. Everyone has equal rights. The law in its majesty allows both rich and poor to sleep under the bridges. And I, a member of the "productive element", get to make $500k+ a year. Perfect atheist "morality".

I consider myself to be pretty healthy individual. I hardly ever go to the doctor. I don't think I need health care. Maybe some emergency insurance, but that's about it. But since I work for a major corporation, I get health care anyway. It's a bit of a waste. I think most people under middle age, who do not have chronic problems would do fine with mere emergency insurance.

I found someone discuss some health care reforms which you may find interesting: http://market-ticker.org/archives/1187-Health-Reform-Who-Are-They-Trying-To-Fool.html

As Shai sayed, one of the things that helps keep the cost of medical care down in Israel is "controls on medical school expenses (the government subsidizes universities) . . ." I'm of the opinion that doctors could afford to charge less and still make a decent living if they didn't come out of medical school with a debt of hundred thousand or more.

Another problem I've noticed, as a relatively ancient blogger--I'm 60--is the radical increase, since my childhood, in the cost of operating a private medical practice. Back in pre-historic days, when I was a kid, it wasn't the least bit unusual for a doctor to have a solo practice with just one employee, a nurse who, in those days, doubled as a secretary. Okay, obviously, no nurse or PA worth her or his salt would double as a secretary these days. But the main problem, from what I can see, is the huge increase in paperwork. Rare is the solo practitioner who doesn't have at least two, if not three or four, employees to take care of all the paperwork and spend literally hours on the phone with insurance companies--and, given the expense of paying 3-4 employees, rare is the solo practitioner, period, with many physicians entering into partnerships or working for a salary. Socialized medicine may very well make the paperwork problem worse. Would cutting the cost of medical school be an adequate compensation? Since it's unlikely in this country, we'll probably never know.

Healthcare in Israel is cheaper, sure - but is it better? For your run of the mill simple problems, you don't need expensive tests or much choice, but if you needed an organ transplant or treatment for cancer you'd probably want to find yourself in an American hospital.

Additionally, Israel benefits by having a glut of doctors left over from the Soviet immigration. Which is why it's relatively easy to get primary care. Israel is also a tiny country which is why it's so able to centralize expensive care much more efficiently than could a country as large as America.

With respect to drugs too, since the drug companies are largely American and they hold American patents - which foreign states do not have to respect, the American people effectively subsidize the cost of medications for the rest of the world.

"But people who are young and healthy should be forced to pay their part of the medical system's expenses just as they do for social security."

In what way is it "their part"? Indeed, why should I be paying for your retirement?

GI,

"Reality - the only reason Canada can afford its health care system is because we have a tiny army.... You want national health care? You can't have that and an army. Choose."

As we've discussed elsewhere, healthcare in Canada costs a smaller percent of GDP than does American healthcare of American GDP today. By proportion, America should be able to afford both.

Moshe,

"I.e., let the elderly and disabled fend for themselves. Everyone has equal rights. The law in its majesty allows both rich and poor to sleep under the bridges. And I, a member of the "productive element", get to make $500k+ a year. Perfect atheist "morality"."

This is the classic example of a yokel with a fake sense of moral superiority. Since I don't favor government handouts that must mean that I want the elderly to die in the street, right?

In fact, what I had said very clearly was that I favor charity care for those in need. People like you think it's alright to just steal people's hard earned money - I prefer that you ask for it first. The money that people earn is first and foremost THEIR MONEY to spend as they choose - they earned it, didn't they? Who are you to see yourself as some noble thinker merely because you think you can spend his money better than him?

Spinoza,

"I think most people under middle age, who do not have chronic problems would do fine with mere emergency insurance."

Probably. But it's obviously the healthy people who are great to help defray the cost of healthcare for everyone else.

Shira,

"I'm of the opinion that doctors could afford to charge less and still make a decent living if they didn't come out of medical school with a debt of hundred thousand or more."

Sure, that's part of it, but not a huge part. If every doctor in America worked for free American healthcare would still outspend other countries by large margins.

"Socialized medicine may very well make the paperwork problem worse."

Or possibly better since a single-payer system would conceivably simplify things. I think our current system with its myriad private insurances is a huge mess all on its own. It seriously offends me that "medical billing" is a career path all of its own in this country.

>It seriously offends me that "medical billing" is a career path all of its own in this country.

In my early 20s I worked as a medical biller. It was a small business. Little did I know at first that the owner had a scam a long with a doctor across the street. The doctor would hall in poor patients with Medicaid, do some simple tests, then send over the paper work to us to bill Medicaid. I noticed something odd when each bill had the exact same medical billing code. (ie. every test done had a particular code that you would X on and bill to Medicaid.) This would insure Medicaid would pay up since they knew which test Medicaid ALWAYS paid for. And this was done to THOUSANDS of patients.

"Since I don't favor government handouts that must mean that I want the elderly to die in the street, right?"

I never said that. But don't let that stop you. The position you took in your post was certainly detrimental to their level of medical care.

"In fact, what I had said very clearly was that I favor charity care for those in need."

You mean the same charity care system that was in place b/f Medicare was enacted in 1965? It worked so wonderfully, didn't it? Amazing why anyone felt the need for a government program! [Maybe because poor elderly people were not receiving remotely adequate medical care. Apparently, the charity of the medical profession was not enough.]

"People like you think it's alright to just steal people's hard earned money - I prefer that you ask for it first. The money that people earn is first and foremost THEIR MONEY to spend as they choose - they earned it, didn't they?"

Last time I looked, duly enacted payroll taxes were not considered theft. By your logic, any income taxation should be considered thievery.

But my main intention was not to debate politics or economics with you. Rather, it was to demonstrate the moral depths to which you can plummet when you jettison the objective morality of Judaism, which teaches that we are our brother's keepers. Sounds to me like you would prefer the atheistic "morality" of, say, Ayn Rand [" Man['s] own happiness [is] the moral purpose of his life, with productive achievement as his noblest activity, and reason as his only absolute."]

Now, skeptics like you love to criticize the alleged immorality of Judaism and the super-frummies. I make a distinction between the two. Based on recent events, I would most certainly join you in your criticism, insofar as the conduct of the super-frummies is concerned. Too many so-called frummies pervert the Torah.

But if your own "morality" is really so selfish, you may pardon some of us for discounting the barbs you have in the past leveled at the Torah.

"The position you took in your post was certainly detrimental to their level of medical care."

Hardly. But I guess you're free to hold pretend certainties.

"You mean the same charity care system that was in place b/f Medicare was enacted in 1965? It worked so wonderfully, didn't it? Amazing why anyone felt the need for a government program! [Maybe because poor elderly people were not receiving remotely adequate medical care. Apparently, the charity of the medical profession was not enough.]"

Maybe, but also a false assumption. If you know anything from history you'd know that the issue for Medicare was not that the elderly were not getting adequate care but that the elderly were felt to be entitled not to "be abandoned to the indignity of charity" as President Truman put it.

"Last time I looked, duly enacted payroll taxes were not considered theft. By your logic, any income taxation should be considered thievery."

Any tax particularly designed to coercively take one person's earned money and give it unearned to a second person is theft. How is it anything else? Last time you looked you were checking into a convenient ethical myth.

"Rather, it was to demonstrate the moral depths to which you can plummet when you jettison the objective morality of Judaism, which teaches that we are our brother's keepers."

And you made a poor demonstration of this since I confirmed a moral obligation for generous charity. It seems that it isn't me but you who is forgetting little Torah gems like "LO TIGNOV."

"Now, skeptics like you love to criticize the alleged immorality of Judaism and the super-frummies."

Actually I don't. I note it when I see ethical problems that require pointing out since they ought to be fixed but it's not something I even like to discuss.

"But if your own "morality" is really so selfish, you may pardon some of us for discounting the barbs you have in the past leveled at the Torah."

Yes, my morality as represented by generous charity and not stealing is obviously of inferior quality. Touche, sir.

Though I feel the need to additionally point out that any moral lapses I may have doesn't somehow dismiss any lapses you may have.

"Any tax particularly designed to coercively take one person's earned money and give it unearned to a second person is theft."

That's pretty much what any tax does. Do you at least realize how far out of the political mainstream such thinking is? Did you vote for Ron Paul? He has a medical degree too.

" I confirmed a moral obligation for generous charity."

Yes, and we all should be nice to each other, drive courteously, and always be honest. But the reality is that the populace as a whole will not always thus act of its volition. And if you advocate a charity medical system, then de facto you are dooming millions of poor people to inadequate medical care. That is immoral.

"If you know anything from history you'd know that the issue for Medicare was not that the elderly were not getting adequate care but that the elderly were felt to be entitled not to "be abandoned to the indignity of charity"..."

It's not just indignity.

Diana Stein,Professor Emeritus, Mount Holyoke College, writes:

"Before Medicare was passed only 44% of seniors were insured and now only 1% of this population lacks coverage.

During the decades since this legislation was enacted, we have seen life expectancy rise from 70 years (1965) to 77.4 years (2005). Many medical advances have occurred that are partially responsible for this increase, of course, but insured health care for the elderly has played a part too. Studies have shown that outcomes for diabetes are better for those on Medicare than those who are near elderly (62-64 years). Similar results were obtained for cardiovascular disease."

But let's assume for sake of argument that the care they received was adequate. Consider the following from a recent NYT article: "When Medicare was established, many older Americans had no private insurance at all — and many were going bankrupt when they became seriously ill. Medicare has been “an invaluable safety net,” said Karen Ignagni, the chief executive of America’s Health Insurance Plans, which represents the nation’s private insurers.

Even those who favor private-sector competition over government intervention say Congress needed to step in. “Medicare was designed to address a real problem,” said Robert E. Moffit, the director of the Heritage Foundation’s Center for Health Policy Studies. “There was a market failure.”

That seniors were going bankrupt before Medicare demonstrates that, left to its own devices, the medical profession did not and will not provide sufficient charity care. Your idea will force seniors into bankruptcy again. That's also immoral.

"It seems that it isn't me but you who is forgetting little Torah gems like "LO TIGNOV."

You don't seriously believe that "Lo Tignov" applies to duly enacted taxes of a legitimate government , do you? Can you cite any authority for that proposition? (Ayn Rand doesn't count).

"But I honestly do appreciate your efforts to hijack the thread."

I don't consider commenting on the morality of your health reform proposal to be hijacking. But it's your blog, and if you don't want me to comment on it, then say so straight out, and I won't. If my comments make you uncomfortable, fine. But spare me the "hijacking" nonsense. Personally, I think we learn best by spirited debate with those with whom we disagree, as opposed to an amen corner.

"That's pretty much what any tax does. Do you at least realize how far out of the political mainstream such thinking is?"

Wrong. Most taxes exist in purpose to help society in general. Fixing the roads, paying for police, regulatory agencies, NASA, whatever - their function isn't to take from one individual and give to another. Welfare and the like is pure Robin Hood.

Just because I'm not mainstream doesn't mean I'm wrong.

"Yes, and we all should be nice to each other, drive courteously, and always be honest. But the reality is that the populace as a whole will not always thus act of its volition."

And therefore if you can't get funding legitimately you think it's ok to just steal it? Interesting. I think there are plenty of nice people in America who will step up to the plate when a necessary charity presents itself.

"And if you advocate a charity medical system, then de facto you are dooming millions of poor people to inadequate medical care. That is immoral."

You don't know anything like this 'de facto.' For all you know, America could raise more money on a charity basis than the government collected for Medicare.

"Before Medicare was passed only 44% of seniors were insured and now only 1% of this population lacks coverage. During the decades since this legislation was enacted, we have seen life expectancy rise from 70 years (1965) to 77.4 years (2005). Many medical advances have occurred that are partially responsible for this increase, of course, but insured health care for the elderly has played a part too."

Does Diana Stein have any real data and not just opinion? I say that the difference is due almost entirely to medical advancements since 1965. If you ever were to look at the actual life expectancy statistics what you will not find is any jump in lifetimes after 1965, but the same kind of progress in the statistics as before 1965.

"Studies have shown that outcomes for diabetes are better for those on Medicare than those who are near elderly (62-64 years). Similar results were obtained for cardiovascular disease."

Of course, because charity for healthcare doesn't exist today so if they're not on Medicare they have nothing. Now why do you think that is? Do you think dependence on the government is a good thing?

"That seniors were going bankrupt before Medicare demonstrates that, left to its own devices, the medical profession did not and will not provide sufficient charity care. Your idea will force seniors into bankruptcy again. That's also immoral."

The greatest irony here is evident by your ignorance. Because of healthcare's out of control costs (only aided by the existence of 'free' public money) seniors are NOW paying MORE out of pocket by percentage of average income than they did before Medicare existed!

http://www.pnhp.org/news/2003/october/seniors_were_better_.php

"You don't seriously believe that "Lo Tignov" applies to duly enacted taxes of a legitimate government , do you? Can you cite any authority for that proposition?"

Why do I need an authority? How does anyone have the right to coercively take one person's earned money and give it to someone else? I know it's easier for folks like you to not think about the actual filching that goes on through taxation, but it's there regardless.

Once you start thinking about real people and the money that they worked hard to earn maybe you wouldn't be so careless about taking it from them. Oh, but you're the moral one here, right.

"I don't consider commenting on the morality of your health reform proposal to be hijacking."

It's funny how you twist what I say and come back with absurd responses. It's not hijacking to comment on my post but this post isn't about my criticism of Torah or religious Jews and you would be hijacking the thread if you turned it into that.

Government confiscation. If I don't drive, why should I have to pay for roads for other people. A system of private roads worked quite well into the 19th century, and might again.

"paying for police"

Just give everyone a gun and we can protect ourselves. Why should I pay to protect other people who won't bother to learn firearms defense?

"regulatory agencies"

What gives the government a right to "regulate" private industry? I don't need some liberal-communist bureaucrat telling me what's good for me.

"NASA"

Don't they have private space rides now. Why must the Gov do this?

"Just because I'm not mainstream doesn't mean I'm wrong."

Granted. But it should give you pause.

"seniors are NOW paying MORE out of pocket by percentage of average income than they did before Medicare existed!"

Thank you for pointing that out to me. But, upon reflection, it occurs to me that the reason may be due to the fact that health care costs have gone thru the roof since then. I doubt whether they would be paying more now if health care costs had kept pace with the general rate of inflation.

"Once you start thinking about real people and the money that they worked hard to earn maybe you wouldn't be so careless about taking it from them."

I bet I pay more taxes than you do [my understanding being that you are in , or have just graduated from, medical school]. I report all my income, including cash income that I could probably get away with not reporting. I don't necessarily always enjoy doing so. I realize that a not insignificant portion of my tax dollar is wasted by fraud, corruption and ineptitude. I believe that the government should not get involved with something that the private sector is handling more or less adequately. But it's my civic [and legal] duty to support my society by paying taxes, and that is as it should be. I try and vote for those whom I think will best contain the fraud, corruption and ineptitude. and limit government involvement in the private sector.

"For all you know, America could raise more money on a charity basis than the government collected for Medicare."

And I may be playing center field for the Cubs next year if I just work hard enough at it.

"Oh, but you're the moral one here, right."

I am but a sinner and a transgressor, and freely admit that. I do try and aspire to something better, though. Like a sense of compassion and empathy for the problems of my less fortunate brethren.

The idea of Medicare/Medicaid is indeed a noble one. That is not meant to be sarcastic, but I also care about the real world consequences of what plans like Medicaid (less Medicare) has done to the society as a whole. I see nothing worse for a society and invididuals than them having a feeling of "entitlement" (which ALWAYS leads to ingratitude). It prevents people from growing and becoming better people. You literally have neighborhoods upon neighborhoods of people doing nothing but expecting the government to hold their hand through life. When government gives people free things a soceity feels they have a right to that no matter what. There is no gratitude and no attempt of bettering yourself. If something comes from charity, people have more of an understanding that this is coming from the caring hearts of their fellow man. When its government, there is no heart and it is so much easier for them to cheat them. And billions of dollars are cheated. The chain reaction of what happens to a society that feels that others "owe" them is nothing I can find redeeming or inpar with Judaism. Cause the truth is, this chain reaction WILL occur.

Look at my state of California. That for years it has done nothing but spend and spend and spend on social services. Look at the outcome. Is this Jewish morality? No. I beleive Jewish morality insists on us having a healthy functioning society. A people depending on their government has pretty much consistently back fired and created worser people.

I don't disagree with much of what you say. But I think its more applicable to welfare than to Medicare. In any event, there is a huge gulf between total reliance on the government on the one hand, and total government abstention on the other. I think the solution lies somewhere in the middle. The key thing is to focus the programs on those who cannot reasonably help themselves. I do not, for example, advocate providing welfare to able bodied people who can reasonably be expected to work.

The fraud problem you mention is also real. And I do not claim that Judaism mandates any particular governmental intervention. The government cannot overextend itself, witness the problems in your state. But I do feel that Judaism teaches us that it is very important to be concerned with the needs of the less well off. Indeed, the Tanakh is replete with admonitions against kings and officials who do not provide adequately for the poor. In our own day, it is our government that occupies the place of these kings and officials.

By all means, minimize the fraud and give people incentive to be self sufficient, but at the end of the day, "the poor shall not cease from the land", and it is both our AND our government's responsibility to assist them.

The Torah mandates that we give Tzedakah individually. Think of part of your taxes as the government doing the same thing for us.

BTW, the no government all charity approach was more or less in effect in 1929. Didn't work so well. Thank God we have a governmental safety net now, or our economic crisis would be a lot worse. Fascists and communists marched in the streets in the 1930's, and there was a real possibility that our democracy would be lost.

We Jews are merciful, children of merciful parents. We should act as a light to influence our government in that direction.

What will cheapen the price of healthcare is tort reform, plain and simple. Texas and California did it and their average cost per person went from something like 3000 to 1500. But that wont happen with obama in charge.

As a matter of principle I am actually sympathetic to many of these types of arguments but whether you agree or not with the merits of these programs they exist to benefit society generally. In distinction, welfare-type programs exist purely in place of charity. They tax the people above and beyond the general upkeep of society which every citizen has implicit interest in. And they mentally entitle the unentitled.

"Granted. But it should give you pause."

In a time of universal deceit, telling the truth becomes a revolutionary act. - HL Mencken.

"But, upon reflection, it occurs to me that the reason may be due to the fact that health care costs have gone thru the roof since then."

And part of the reason they have risen so high is because these public programs (and even private insurance) largely hide the true cost of business from the people receiving care. People are all too willing to get the most expensive care when they aren't footing the bill. If patients were direct customers they'd pay much closer attention to what they were billed and costs would go down.

"I bet I pay more taxes than you do.."

Probably so, but just because you accept being filched doesn't suggest a moral standing to permit others to be filched.

>We Jews are merciful, children of merciful parents. We should act as a light to influence our government in that direction.

I agree with the first part, but governments tend to always make matters worse especially when they are so large and in charge of such a huge population. I am not ready to get rid of Medicare yet, but I am also not ready to put the whole country on a medicare like program that ends up making things worse for the population as a whole. The United States has too many "do-gooders" that thrive on creating a nanny state, and the less power I give them, the better a society we can become.

> In our own day, it is our government that occupies the place of these kings and officials.

I don't say government should do nothing, but where is the line? California is learning this the hard way that you can't spend and spend and spend on social welfares and not have consequences. And now, people are basically entrenched in a certain mode of feeling they are owed a certain amount and things never change.

>Think of part of your taxes as the government doing the same thing for us.

a) They do a lousy job at it and it creates a domino affect for other problems. I have seen more doctors refusing to take Medicaid for example because they realize its just not worth it.b) It's not charity when you have a gun to your head forcing you to put it into programs that you disagree on.

OP, "If patients were direct customers they'd pay much closer attention to what they were billed and costs would go down."

I actually agree with you on this point. But there are some people who, through no fault of their own, will never have the means to pay for adequate health care, and they have to be taken care of.

"do you think the government knows how to better give away your money than you do?"

No I don't. But I realize from historical experience that the laissez-faire approach doesn't work. So I accept some infringement on my freedom for the greater good.

At the end of the day, though, it is clear that the present system is not economically sustainable. Solutions need to be practical, not ideologically pure. [Ideological solutions generally do not work so well in the real world]. Trial and error is often the best guide. If it were up to me, I'd start with the following:

1. A system of clinics/hospitals, run by the government, to attend to the needs of those who need government assistance [e.g., poor elderly and the disabled]. Only those who qualified financially could be treated at these institutions [except perhaps for some emergency room issues].

2. By law physicians at these clinics would be on salary in the 150k vicinity [i.e., no incentive to run unnecessary tests]. They would be required to work up to 50 hours a week, , no more than 10 hours per day, and would receive 4 weeks vacation, and excellent benefits, including malpractice insurance.

3. Physicians in these clinics, and the clinics themselves, would not be subject to suit for pain and suffering for malpractice, absent willful wrongdoing, or recklessness. Even then, there would be no jury trial.There would though be a mechanism for weeding out from the profession any doctors who committed repeated acts of negligence.

4. The mass paperwork currently required would be eliminated.

5. Generic drugs only would be used, absent a clear and major benefit from a brand name.

6. Nurse practitioners would be used in lieu of physicians for routine matters.

7. Patients receiving an income of some sort would have to pay small co-pays, or have same deducted from there income.

8. Student loan payments would be made for the doctors as long as they were employed by the clinic.

9. Initiate a massive publicity campaign by the government, to warn of the dangers of obesity and of eating too much fat [particularly saturated fat] and simple carbohydrates. Restaurants would have to post nutritional information as to each item on the menu. Foods meeting certain criteria would have to carry a warning label, similar to cigarettes.

10. Allow the free importation and use of FDA approved drugs manufactured overseas.

11. Take away tax deduction from employers for health insurance. Replace with a deduction for individuals earning not more than a certain amount, and a tax credit for the working poor.

12. While there would be minimum standards and practices in force, waiting times at the clinics would be significantly more than in the private sector. The idea is to give adequate treatment, but no more, and to thus encourage anyone who is able to to opt out of the system in favor of the private system.

13. A bidding system to hire private auditors to audit each clinic annually to prevent fraud and waste. The auditors would be financially rewarded out of any savings recovered.

14. I would hope that the fixed hours, reasonable salary, lack of paperwork, student loan payments and loss of malpractice exposure would attract enough physicians to work in the clinics. If not, licensing requirements for foreign physicians could be eased, and the foreign physicians recruited.

HH, I saw your 7:25 PM post after I wrote my last comment. I have tried to address some of your concerns in my 14 "points". In proposing 14 points, I am of course humbled by what the French premier Clemenceau is reputed to have said about President Wilson's proffered 14 points during WWI: "God gave us 10 commandments, and we broke them. Wilson gives us 14 points. We shall see".

"But there are some people who, through no fault of their own, will never have the means to pay for adequate health care, and they have to be taken care of."

Sure, here enters charity.

" A system of clinics/hospitals, run by the government, to attend to the needs of those who need government assistance [e.g., poor elderly and the disabled]. Only those who qualified financially could be treated at these institutions [except perhaps for some emergency room issues]."

Heh, it's funny but I was speaking to my friend the other day and this was pretty much the plan I had thought of myself. Public infrastructure in lieu of public compensation.

"2. By law physicians at these clinics would be on salary in the 150k vicinity [i.e., no incentive to run unnecessary tests]. They would be required to work up to 50 hours a week, , no more than 10 hours per day, and would receive 4 weeks vacation, and excellent benefits, including malpractice insurance."

That sounds competitive for family practice, though the hours are on the short side. And if you're including full fledged hospitals you're going to need to pay for specialists one way or the other. You think a surgeon is going to work for $150k?

Functionally too, you need to appeciate that doctors hate the idea of being hired hands or cogs in a machine. Many docs - especially those in primary care - like the idea of extended relationships with their patients and clinics like yours would have limited long-term retention, though it may succeed on a rolling level of the recently trained.

"4. The mass paperwork currently required would be eliminated."

Heh, that's pure fantasy. More government involvement means more paperwork.

"5. Generic drugs only would be used, absent a clear and major benefit from a brand name."

Except that in-hospital use tends to be offered by big-name companies on a formulary basis at minor cost.

Another idea I've heard not too long ago is the idea that insurance should be set up with what amounts to an allowance of only a couple thousand dollars a year for routine costs of medical care. Above that, the costs are no longer covered and everything is out of pocket or charity-based. This makes the costs apparent to consumers. Finally, after out of pocket expenses hit some monetary limit - perhaps $10,000 (ie more than a person of average means could reliably have available)- insurance hits in for indemnity or catastrophic care.

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